1. ACT for Chronic Pain Delivering Effective Multidisciplinary Treatment to Any Community Joel Guarna, Ph.D. Stephen Hull, M.D.

2. Living Life Well Multidisciplinary, Group Based, Pain Rehabilitation Program Evolution 2

3. Clinically effective and Cost Effective Site visits – Mayo Clinic, Rochester, Minnesota – Cleveland Clinic, Cleveland, Ohio – Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire – Bath Centre for Pain Services, Bath, England, UK 3 Multidisciplinary Pain Rehabilitation

4. Feasibility Assessment Population demographics – Predominantly disabled Payors – Medicaid (MaineCare) – Medicare and Medicare Disability – Charity Care – Commercial Insurance – Disability and Workers Compensation Staffing 4

5. Treatment Team Physician - Physiatrist, Algiatrist Physical Therapy Assistant Psychologist Clerical Support - Coordinator Scalable to Any Community of Pain Patients 5

6. Treatment Team Physician - Interested Physician Exercise Director Behavioral Therapist Clerical Support - Coordinator Appropriate Space (CBT and Exercise) Scalable to Any Community of Pain Patients 6

7. Exclusion (Admission) Criteria Medical and Psychological 7

8. Exclusion (Admission) Criteria Non-Acute (Chronic) Pain – Reasonable symptom reduction options Medical contraindications to exercise Significant cognitive impairment Inability to work in a group – Social phobia or agoraphobia – History of disruptive behavior VERY severe depression Language, geographic, and financial limitations

9. 9 NEGATIVE SELLING

10. 10

11. Gotta Have a Margin Psychologist - Bills a group therapy charge Physician - Bills an office visit charge Physical Therapy Assistant - no charge Break even is at 3 paying patients Cost is $5,000 - $7,000 11

12. Foundational Day 1 Our Point of View 12

14. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking

15. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking

16. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking Avoid Isolate Hide Sleep Take meds Call dr. Distraction Stretch Call a friend Go for a walk Yoga Breathing exercises Drink Street drugs Compulsive behaviors

17. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking Avoid Isolate Hide Sleep Take meds Call dr. Distraction Stretch Call a friend Go for a walk Yoga Breathing exercises Drink Street drugs Compulsive behaviors Relns Kids Spouse Friend Loving Warm Supportive Close Caring Fun Honest RespRecHealth Caretaker Supportive Responsible Job Dependable Productive Self? Quilting Fishing Hiking Watching Sports Walking Movement Strong

18. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking Avoid Isolate Hide Sleep Take meds Call dr. Distraction Stretch Call a friend Go for a walk Yoga Breathing exercises Drink Street drugs Compulsive behaviors Relns Kids Spouse Friend Loving Warm Supportive Close Caring Fun Honest RespRecHealth Caretaker Supportive Responsible Job Dependable Productive Self? Quilting Fishing Hiking Watching Sports Walking Movement Strong

19. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking Avoid Isolate Hide Sleep Take meds Call dr. Distraction Stretch Call a friend Go for a walk Yoga Breathing exercises Drink Street drugs Compulsive behaviors Relns Kids Spouse Friend Loving Warm Supportive Close Caring Fun Honest RespRecHealth Caretaker Supportive Responsible Job Dependable Productive Self? Quilting Fishing Hiking Watching Sports Walking Movement Strong

20. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking Avoid Isolate Hide Sleep Take meds Call dr. Distraction Stretch Call a friend Go for a walk Yoga Breathing exercises Drink Street drugs Compulsive behaviors Relns Kids Spouse Friend Loving Warm Supportive Close Caring Fun Honest RespRecHealth Caretaker Supportive Responsible Job Dependable Productive Self? Quilting Fishing Hiking Watching Sports Walking Movement Strong

21. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking Avoid Isolate Hide Sleep Take meds Call dr. Distraction Stretch Call a friend Go for a walk Yoga Breathing exercises Drink Street drugs Compulsive behaviors Relns Kids Spouse Friend Loving Warm Supportive Close Caring Fun Honest RespRecHealth Caretaker Supportive Responsible Job Dependable Productive Self? Quilting Fishing Hiking Watching Sports Walking Movement Strong

22. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking Avoid Isolate Hide Sleep Take meds Call dr. Distraction Stretch Call a friend Go for a walk Yoga Breathing exercises Drink Street drugs Compulsive behaviors Relns Kids Spouse Friend Loving Warm Supportive Close Caring Fun Honest RespRecHealth Caretaker Supportive Responsible Job Dependable Productive Self? Quilting Fishing Hiking Watching Sports Walking Movement Strong

23. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking Avoid Isolate Hide Sleep Take meds Call dr. Distraction Stretch Call a friend Go for a walk Yoga Breathing exercises Drink Street drugs Compulsive behaviors Relns Kids Spouse Friend Loving Warm Supportive Close Caring Fun Honest RespRecHealth Caretaker Supportive Responsible Job Dependable Productive Self? Quilting Fishing Hiking Watching Sports Walking Movement Strong

24. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking Avoid Isolate Hide Sleep Take meds Call dr. Distraction Stretch Call a friend Go for a walk Yoga Breathing exercises Drink Street drugs Compulsive behaviors Relns Kids Spouse Friend Loving Warm Supportive Close Caring Fun Honest RespRecHealth Caretaker Supportive Responsible Job Dependable Productive Self? Quilting Fishing Hiking Watching Sports Walking Movement Strong

25. Foundational Day 2 Neuro-physiology (Structure-Function) 25

26. 26

27. 27

28. 28

29. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking Avoid Isolate Hide Sleep Drink Street drugs Compulsive behaviors

30. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension Spasms HR up Breathing Fatigue Sharp Radiating Anxious Irritable Annoyed Angry Depressed Hopeless Guilty “I can’t...” “Why?” “I used to...” “Nothing will ever change.” Self-judgments Distraction Attention Memory BodyEmotionsThinking Avoid Isolate Hide Sleep Take meds Call dr. Distraction Stretch Call a friend Go for a walk Yoga Breathing exercises Drink Street drugs Compulsive behaviors What for?

31. Me noticing Outside (5 senses) Inside (mental) TowardAway Pain Tension FatigueAnxious “I can’t...”Attention BodyEmotionsThinking Angry Guilty Depressed “Why?”

32. Me noticing Outside (5 senses) Inside (mental) TowardAway BodyEmotionsThinking Take meds Call dr. Distraction Relns Kids Spouse Friend Loving Warm Supportive Close Caring Fun Honest RespRecHealth Caretaker Supportive Responsible Job Dependable Productive Self? Quilting Fishing Hiking Watching Sports Walking Movement Strong Brief Committe d Actions (BCAs)

33. Me noticing Outside (5 senses) Inside (mental) TowardAway BodyEmotionsThinking Take meds Call dr. Distraction Relns Kids Spouse Friend Loving Warm Supportive Close Caring Fun Honest RespRecHealth Caretaker Supportive Responsible Job Dependable Productive Self? Quilting Fishing Hiking Watching Sports Walking Movement Strong Stretch Call a friend Go for a walk Yoga Breathing exercises Mindfulness Mindful Activities

34. Outside (5 senses) Inside (mental) TowardAway BodyEmotionsThinking Take meds Call dr. Distraction Relns Kids Spouse Friend Loving Warm Supportive Close Caring Fun Honest RespRecHealth Caretaker Supportive Responsible Job Dependable Productive Self? Quilting Fishing Hiking Watching Sports Walking Movement Strong Me noticing

35. Hooligans on the Bus 35

36. Me noticing Outside (5 senses) Inside (mental) TowardAway Relapse Preparedness Warning Signs

37. Outcomes 37

38. Outcome Physical Measures Affective Measures – PHQ-9 – GAD-7 Functional Measures – Chronic Pain Acceptance Questionnaire (CPAQ) – Treatment Outcomes of Pain Survey, Short (S- TOPS) – Medical Outcomes Study Sleep Scale – Oswestry Disability Index – Neck Disability Index 38

43. Average score on admission 28.5

44. Average score on admission 17.7

48. Mindfulness Resources Websites:www.sittingtogether.comwww.sittingtogether.com www.ayearofbeinghere.com Neurophysiology Resources Book: Explain Pain by David Butler and Lorimer Moseley Blog: http://explainpain.blogspot.comhttp://explainpain.blogspot.com Listserve: http://www.bodyinmind.org YouTube Video: Lorimer Moseley TED Talk https://www.youtube.com/watch?v=gwd-wLdIHjs Understanding Pain: What to do about it in less than 5 minutes https://www.youtube.com/watch?v=4b8oB757DKc

49. joel.whitepine@gmail.com hulls@emhs.org